1104022409 NPI number — JAMES M GREEN PS

Table of content: (NPI 1104022409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104022409 NPI number — JAMES M GREEN PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES M GREEN PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104022409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 SHERIDAN RD.
Provider Second Line Business Mailing Address:
#109
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98310-2701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-377-3395
Provider Business Mailing Address Fax Number:
360-792-1249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 SHERIDAN RD.
Provider Second Line Business Practice Location Address:
#109
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-377-3395
Provider Business Practice Location Address Fax Number:
360-792-1249
Provider Enumeration Date:
06/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
360-377-3395

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00002393 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8141202 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: WA7267008 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 190150200 . This is a "FEDERAL DEPT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0197563 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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